Ruptured spleen due to blunt trauma in children: analysis of blood transfusion requirements.

Selective non-operative management of splenic injury in children is generally considered to be safe, and the majority of those with isolated injuries do not require blood transfusion. Eighty-four children were treated for blunt splenic trauma from 1988 to 1997 in the Department of Paediatric Surgery, The Medical Faculty of Uludag University, Bursa, Turkey. Management involved non-operative care in 56 cases (66.7%), splenectomy in 20 (23.8%) and splenorraphy in eight (9.5%) cases. There were no later complications related to splenic injury. The overall mortality was 9.5% (8/84) and the factors effecting mortality were additional intra-abdominal and/or other system injuries. Twenty-two children were not transfused during non-operative treatment. In our study, only 57.1% of the children in the non-operative group received blood transfusions. Some of the patients in this group received only small amounts of blood and probably would have recovered without it. It is concluded that, based on a very strict protocol in conservative management, the total amount of transfused blood could be reduced in children with splenic injuries due to blunt abdominal trauma.     

Pediatric sledding trauma: avoiding the collision

During 2006-2007, a midwest pediatric level I trauma center and affiliated urgent care centers treated 181 children for sledding-related trauma. Twenty-one children required hospitalization for injuries. Some children sustained injuries that were severe including cervical fracture with spinal cord injury, splenic laceration, pulmonary contusion, and head injury. The most frequent mechanism of injury was collision with an object or a person. Although most injuries are minor, some are serious and may have life-changing outcomes. Sledding in unobstructed areas may decrease injuries. An increased public awareness of the risks of serious injury associated with sledding is needed.     

动脉造影及超选择栓塞治疗闭合性肝脾外伤

目的　探讨动脉造影诊断及超选择栓塞止血治疗闭合性肝、脾外伤的价值。方法　对 15例确诊或可疑闭合性肝、脾外伤患者采用改良Seldinger法进行动脉造影诊断及确诊后用明胶海绵或弹簧圈超选择栓塞止血治疗 ,观察术后疗效。结果　 15例均得以确诊并一次栓塞止血成功 ,术后恢复顺利 ,半年以上随访无特殊变化。结论　动脉造影诊断及超选择栓塞止血治疗闭合性肝、脾外伤安全、有效 ,病情恢复快 ,具有较高的临床应用价值。     

Comparison of Gray-Scale Contrast-Enhanced Ultrasonography with Contrast-Enhanced Computed Tomography in Different Grading of Blunt Hepatic and Splenic Trauma: An Animal Experiment

To compare the diagnostic value of contrast-enhanced ultrasonography (CEUS) with contrast-enhanced computed tomography (CECT) for the detection of different grading of solid organ injuries in blunt abdominal trauma in animals. A self-made miniature tools were used as models to simulate a blunt hepatic or splenic trauma in 16 and 14 anesthetized dogs, respectively. Baseline ultrasound, CEUS and CECT were used to detect traumatic injuries of livers and spleens. The degree of injuries was determined by CEUS according to the American Association for the Surgery of Trauma (AAST) scale and the results compared with injury scale based on CECT evaluation. CEUS showed 22 hepatic injury sites in 16 animals and 17 splenic injury sites in other 14 animals. According to AAST scale, 2 grade I, 4 grade II, 3 grade III, 5 grade IV and 2 grade V hepatic lesions were present in 16 animals; 2 grade I, 4 grade II, 6 grade III and 2 grade IV splenic lesions in 14 animals. On CECT scan, 21 hepatic and 17 splenic injuries were demonstrated. According to Becker CT scaling for hepatic injury, 1 grade I, 2 grade II, 4 grade III, 5 grade IV and 2 grade V hepatic injuries were present. On the basis of Buntain spleen scaling, 2 grade I, 5 grade II, 5 grade III, 2 grade IV splenic injuries were showed. After Spearman rank correlation analysis, the agreement of CEUS with CECT on the degree of hepatic and splenic injury is 93.3% and 92.9%, respectively. CT is currently considered as the reference method for grading blunt abdominal trauma, according to experiment results, CEUS grading showed high levels of concordance with CECT. CEUS can accurately determine the degree of injury and will play an important role in clinical application. (E-mail: txiner@vip.sina.com)     

Boarder belly: splenic injuries resulting from ski and snowboarding accidents

Objective: Snowboarding has increased in popularity worldwide, with an associated increase in injuries suffered by its participants with a significant proportion of these injuries being severe. We sought to understand the risk of sustaining a splenic injury in snowboarders as compared to skiers, and whether there are noteworthy differences in their characteristics at hospital admission. Methods: A 10‐year retrospective review was conducted on patients with splenic injury resulting from snowboarding or skiing, who were admitted to the principle ED and referral hospital servicing several busy downhill skiing areas. Population‐based injury rates were calculated for our catchment area, using data provided by the Canadian Ski Council. Results: Controlling for gender, snowboarders were six times more likely to sustain a splenic injury than skiers (P < 0.0001). The risk of splenic injury was 21.7 times greater for male snowboarders than for female snowboarders (P = 0.002). By contrast, no gender differences were observed for skiers. Snowboarders admitted to hospital with a splenic injury were significantly younger, more likely to present with an isolated injury and to required a shorter hospital stay, as compared to skiers. Conclusion: The risk of sustaining an injury of the spleen resulting from blunt abdominal trauma while snowboarding is significantly greater than the risk while downhill skiing. Male snowboarders have a significantly higher risk of splenic injury than female snowboarders. In the majority of cases, snowboarders sustained their injuries as a result of falls or jumps.     

Reevaluation of ultrasonography for solid-organ injury in blunt abdominal trauma.

OBJECTIVE: To reevaluate the usefulness of ultrasonography for detecting and classifying solid-organ injuries from blunt abdominal trauma by comparing ultrasonography with computed tomography (CT) and laparotomy. METHODS: Six hundred four patients with blunt abdominal trauma were examined by both B-mode ultrasonography and CT for a study period of 14 years. The ultrasonographic examiners were divided into 2 groups depending on their experience with ultrasonography. The ultrasonographic results were then compared with CT and surgical findings. This was a retrospective study. RESULTS: In 198 patients, solid-organ injuries were identified on CT, laparotomy, or both. Sensitivity values in group A (experts) were 87.5% for hepatic injuries, 85.4% for splenic injuries, 77.6% for renal injuries, and 44.4% for pancreatic injuries. Sensitivity values in group B were 46.2% for hepatic injuries, 50.0% for splenic injuries, and 44.1% for renal injuries. The detection rates in group A were 80% to 100% for different types of hepatic injuries except superficial injuries (20%) and 70% to 100% for different types of splenic injuries. The detection rates for renal parenchymal and pancreatic duct injuries were 53.3% and 80%, respectively. The detection rates for injuries requiring intervention were 86.1% in group A and 66.7% in group B. CONCLUSIONS: The sensitivity of ultrasonography with the use of CT and surgical findings as reference standards decreased compared with our prior study. However, ultrasonography was found to enable experienced examiners to detect and classify parenchymal injuries efficiently, despite disadvantages in detecting superficial and vascular injuries. Ultrasonography should be used to explore not only free fluid but also solid-organ injuries.     

Multimodality ultrasound assessment of the spleen: Normal appearances and emergency abnormalities

This paper summarizes the main splenic emergencies and their ultrasonographic findings to orient appropriate patient management. US requires minimal preparation time and allows to examine the parenchyma and to detect intraperitoneal fluid collections, which may be indirect evidence of solid organ injuries. In this paper, we analyze the role of B-mode, Doppler and Contrast-Enhanced Ultrasound in the diagnosis of splenic emergencies, with a particular focus on splenic infarction, infection, traumatic injuries and vascular splenic anomalies.     

Ultrasound detection of free intraperitoneal fluid associated with hepatic and splenic injuries

BACKGROUND: The objective of this study was to compare the sensitivity and specificity of 5 abdominal views for detecting free intraperitoneal fluid in trauma patients later diagnosed with hepatic or splenic injuries. METHODS: This retrospective study conducted over a 17-month period enrolled patients with trauma. A Focused Abdominal Sonogram for Trauma (FAST) examination was done using 5 abdominal views. Exploratory laparotomy or computed tomography (CT) confirmed the presence of intraperitoneal fluid and associated injuries. The sensitivity and specificity were determined. RESULTS: Of the 245 study patients, 29 had injuries to the liver or spleen or both. The 5-view FAST examination's sensitivity for detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 77%, 90%, and 100%, respectively. The sensitivity of the single Morison's pouch view in detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 38%, 20%, and 67%, respectively. CONCLUSION: For identifying free intraperitoneal fluid associated with hepatic or splenic injuries, no single view of the FAST examination could match the sensitivity provided by the 5-view technique.     

医源性脾损伤的防治对策

目的：分析医源性脾损伤的原因,并探讨其预防和治疗对策。方法：对1984年7月—2009年7月21例与手术有关的脾损伤患者的临床资料进行回顾分析。结果：21例脾损伤发生于胃手术9例（42.8%）,结肠手术6例（28.6%）,肝脏手术3例（14.3%）,其他手术3例（14.3%）。各例均经手术治愈,其中行脾切除术12例（57.1%）,脾修补术4例（19.1%）,局部止血5例（23.8%）。结论：医源性脾损伤大多数是可以预防的,根据脾损伤的程度选择合理术式是治疗的关键。     

Sonographic patterns of intraperitoneal hemorrhage associated with blunt splenic injury.

OBJECTIVE: To determine the correlation between sonographic detection of free fluid in the left upper quadrant and blunt splenic injury. METHODS: A retrospective review was conducted of all consecutive emergency blunt trauma sonograms obtained at a level I trauma center from January 1995 to January 2001. Data were collected on demographics, free fluid location, and patient outcome. Injuries were determined from computed tomography, diagnostic peritoneal lavage, laparotomy, or a combination thereof. RESULTS: A total of 4320 blunt trauma sonograms were obtained, and 596 patients (14%) had intra-abdominal injuries. The mean age was 33.7 +/- 19.1 years (range, 1-95 years), with 294 (49%) male and 302 (51%) female. There was no statistical difference between age, sex, or mechanism for all subgroups. There were 409 true-positive, 187 false-negative, 88 false-positive, and 3636 true-negative findings. Sensitivity of sonography for detecting all intra-abdominal injuries was 68%, and specificity was 97.6%; sensitivity for detecting isolated splenic injuries was 73.8%. Locations of free fluid in patients with nonsplenic injuries were compared with those in patients with splenic injuries. Isolated left upper quadrant free fluid was significantly associated with splenic injury (odds ratio = 3.0; P = .002), followed by diffuse free fluid (odds ratio = 2.1; P = .005). A subanalysis of isolated splenic injuries also revealed a significant association with left upper quadrant free fluid (odds ratio = 3.1; P = .007) and diffuse free fluid (odds ratio = 2.7; P = .0007). CONCLUSIONS: Free fluid in the left upper quadrant is significantly associated with splenic injury. This finding should triage patients more rapidly to computed tomography, angiography, embolization, and laparotomy.     

Iatrogenic Injury to the Spleen—CT Appearance

Splenic injury is a well-known but rare complication of various abdominal surgical and invasive procedures, and even of cardiac surgery. The true incidence of iatrogenic splenic trauma is, however, difficult to assess and is probably underestimated. Overt injuries diagnosed during surgery are usually immediately treated by splenectomy without imaging. This review focuses on missed splenic injuries that are diagnosed on imaging following surgery or an invasive procedure.     

脾损伤保脾治疗32例报告

目的探讨和总结脾损伤保脾治疗的方法和经验。方法回顾性分析1995年1月至2004年6月本院保留脾脏治疗32例脾外伤的临床资料及其治疗结果。结果32例脾外伤中,19例入院时血液动力学稳定,或输血后稳定行非手术治疗,其中17例(占89%)治愈(2例因迟发脾破裂而保脾治疗失败);15例行保留脾脏或脾脏组织手术,均临床治愈。结论严格掌握适应证,非手术治疗和保留脾脏手术是治疗脾外伤的一种安全有效的手段。     

Diagnosis and management of blunt abdominal solid organ injury

PURPOSE OF REVIEW: Nonoperative management of solid organ injuries has become the standard of care for over 25 years. Benefits of this practice include reduced operative complications, reduced transfusions, lower infectious morbidity, and shorter length of stay. Patients eligible for this management practice include those who are hemodynamically stable and who do not have associated injuries that require celiotomy. Operative interventions need to occur expeditiously in hemodynamically unstable patients with hepatic and splenic injuries. RECENT FINDINGS: Recent literature has focused on the continued success with nonoperative management of blunt solid organ injuries. The role of angioembolization for both splenic and hepatic injuries continues to be explored. Other authors are also questioning the appropriateness of clinical decisions for selection of hemodynamically unstable patients for nonoperative management. Operative management of blunt pancreatic trauma remains the rule. SUMMARY: Nonoperative management of solid organ injuries continues to have high success rates in the appropriate patient population. Minimally invasive adjuncts have a definite role in management of this patient population. Pancreatic trauma remains an operative injury. Surgeons must, however, temper the enthusiasm for nonoperative management of patients with solid organ injury, and exclude from this management scheme patients who would best be treated with surgery.     

Splenic trauma: evaluation with contrast-specific sonography and a second-generation contrast medium: preliminary experience.

OBJECTIVE: To report our experience in the assessment of splenic trauma with contrast-coded sonography and a second-generation contrast medium. METHODS: From January to May 2002, 120 patients were studied with sonography for suspected splenic trauma. Twenty-five were selected for further imaging because of sonographic findings positive for splenic injury, findings positive for peritoneal fluid only, indeterminate findings, and negative findings with high clinical or laboratory suspicion. These patients underwent contrast-enhanced harmonic sonography and contrast-enhanced helical computed tomography. RESULTS: Among the 25 patients studied, 6 had no spleen trauma at initial and follow-up evaluation. One patient had a hypoperfused spleen without parenchymal damage, and 18 had splenic injuries; these 19 patients were considered positive. Hemoperitoneum was identified by sonography, contrast-enhanced sonography, and contrast-enhanced computed tomography in 74% of the 19 positive cases. Perisplenic clots were recognized in 58% of the cases by computed tomography and in 42% by baseline and enhanced sonography. Splenic infarctions were found in 11% of cases by contrast-enhanced sonography and computed tomography; none was found by unenhanced sonography. Parenchymal traumatic lesions were identified in 12 of 18 patients with splenic injuries by unenhanced sonography, in 17 cases by contrast-enhanced sonography, and in all 18 cases by contrast-enhanced computed tomography. A minimal splenic lesion was found in the single patient with a false-negative contrast-enhanced sonographic finding. Contrast-enhanced sonography correlated appreciably better than unenhanced sonography in detecting injuries and in estimating their extent. Findings undetectable on unenhanced sonography were also noted: splenic hypoperfusion in 11% of positive cases on both contrast-enhanced sonography and contrast-enhanced computed tomography, contrast medium pooling in 21% of cases on both contrast-enhanced sonography and computed tomography, and contrast extravasation in 11% of cases on computed tomography and 5% on contrast-enhanced sonography. CONCLUSIONS: Contrast-enhanced sonography is a promising tool in the assessment of splenic trauma. In institutions where sonography is used as the initial procedure, this technique may increase its effectiveness.     

Multidetector-Row Computed Tomography Imaging of Splenic Trauma

The spleen is the intra-abdominal organ most often injured as a result of blunt trauma. Multidetector-row computed tomography (MDCT) plays an important role in the detection and characterization of splenic injury. It has been shown to be highly accurate and can detect splenic vascular lesions, the presence of which has been shown to be a predictor of failure of nonoperative management. The increased use of angiography and splenic artery embolization in the management of such injuries has led to improved success rates with nonoperative management. This article reviews the various appearances of the injured spleen and discusses the use of MDCT in the initial evaluation of injury. The indications for angiography and embolization are reviewed, with examples of appearances of the postembolization spleen.     

Treatment of traumatic splenic rupture in children

The introduction of new techniques for reducing blood loss in operations on parenchymatous organs and of ultrasonography for screening the traumatized spleen and monitoring therapeutic management have made it possible to preserve this organ following injuries in childhood with increasing success over the past few years. An analysis of a sample of 48 children with splenic rupture (33 boys, 15 girls, aged between eleven months and four years) treated in our department between 1974 and 1989 illustrates this change of approach. 26 patients were splenectomized, in 14 cases the spleen was partly preserved, and 8 were just monitored.     

Higher incidence of major complications after splenic embolization for blunt splenic injuries in elderly patients

Background

Nonoperative management (NOM) of blunt splenic injuries has been widely accepted, and the application of splenic artery embolization (SAE) has become an effective adjunct to NOM. However, complications do occur after SAE. In this study, we assess the factors leading to the major complications associated with SAE.

Materials and Methods

Focusing on the major complications after SAE, we retrospectively studied patients who received SAE and were admitted to 2 major referral trauma centers under the same established algorithm for management of blunt splenic injuries. The demographics, angiographic findings, and factors for major complications after SAE were examined. Major complications were considered to be direct adverse effects arising from SAE that were potentially fatal or were capable of causing disability.

Results

There were a total of 261 patients with blunt splenic injuries in this study. Of the 261 patients, 53 underwent SAE, 11 (21%) of whom were noted to have 12 major complications: 8 cases of postprocedural bleeding, 2 cases of total infarction, 1 case of splenic abscess, and 1 case of splenic atrophy. Patients older than 65 years were more susceptible to major complications after SAE.

Conclusion

Splenic artery embolization is considered an effective adjunct to NOM in patients with blunt splenic injuries. However, risks of major complications do exist, and being elderly is, in part, associated with a higher major complication incidence.     

The role of hospital profit status in pediatric spleen injury management

BACKGROUND: Evidence suggests that over 90% of pediatric splenic injuries can be successfully managed nonoperatively. Although pediatric hospitals have rapidly adopted nonoperative management, variability exists among other types of hospitals. OBJECTIVES: We tested 2 a priori hypotheses: (1) spleen-injured children are more likely to receive splenectomy in for-profit hospitals than in not-for-profit hospitals; and (2) hospital charges for spleen cases are greater in for-profit hospital than in not-for-profit hospitals. RESEARCH DESIGN: Multivariable regression was performed with data from the Kid's Inpatient Database (KID) for years 2000 and 2003, controlling for patient and hospital characteristics. Children (0-18 years) hospitalized with a blunt traumatic (noniatrogenic) spleen injury in any of the states participating in KID (N = 5061), including adult and pediatric hospitals. Main outcome measures were splenectomy and hospital charges. RESULTS: A total of 756 children (14.9%) received splenectomies within 1 day of arrival. Splenectomy was found to be more likely among children treated at for-profit hospitals [odds ratio (OR), 1.75; 95% confidence interval (CI), 1.14-2.67] than among children treated in not-for-profit general hospitals. Splenectomies were much less common in children's hospitals (OR, 0.14; 95% CI, 0.05-0.41) than in not-for-profit general hospitals. Hospital charges for all spleen-injured children (regardless of treatment) were significantly greater in for-profit hospitals than in not-for-profit hospitals. CONCLUSIONS: For-profit hospitals seem to be trailing not-for-profit hospitals in the adoption of spleen-conserving management practices. The cost of caring for a child with a splenic injury also seems greater at for-profit hospitals, regardless of management path (ie, splenectomy vs. nonoperative management).     

Use of ultrasonography in the patient with acute renal trauma.

The purpose of this study was to assess the use of emergent ultrasonographic examination in acute traumatic renal injuries. Over a 3 year period, prospective data of all patients who had an emergency ultrasonogram were recorded. Thirty-two patients with 37 renal injuries were studied retrospectively to identify in how many patients the sonogram detected free fluid or a renal parenchymal abnormality. Free fluid in the abdomen was identified in 19 of 32 patients (59%). However, 12 of these 19 patients had concomitant injury, such as splenic rupture requiring splenectomy, severe liver lacerations, or bowel lacerations requiring repair, that were possible causes of the free fluid. Eliminating these patients, only seven of 20 patients with isolated renal injuries had free fluid in the abdomen (35%), whereas 13 of 20 patients (65%) had no evidence of free fluid. All seven patients with free fluid had moderate or severe renal injuries. Renal parenchymal abnormalities were identified on ultrasonograms in eight of 37 (22%) of injured kidneys. The abnormalities were detected more commonly in cases of severe injury (60%). In conclusion, acute injuries of the kidney from blunt abdominal trauma often are associated with significant splenic, hepatic, or bowel trauma. Isolated renal injuries frequently occur without the presence of free fluid in the abdomen. Furthermore, the ultrasonogram of the kidney often is normal with acute renal injuries, but it is more likely to be abnormal with severe (grade II or greater) renal injuries. Sonography may be used in the triage of patients with blunt abdominal trauma and possible renal injury. However, a negative ultrasonogram does not exclude renal injury, and, depending on clinical and laboratory findings, other imaging procedures such as computed tomography should be performed.     

Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging

Background: Cervical spine injuries are difficult to diagnose in children. They tend to occur in different locations than in adults, and they are more difficult to identify based on history or physical examination. As a result, children are often subjected to radiographic examinations to rule out cervical spine injury. Objectives: This two-part series will review the classic cervical spine injuries encountered in children based on age and presentation. Part I will discuss the mechanisms of injury, clinical presentations, and the use of different imaging modalities, including X-ray studies and computed tomography (CT). Part II discusses management of these injuries and special considerations, including the role of magnetic resonance imaging, as well as injuries unique to children. Discussion: Although X-ray studies have relatively low risks associated with their use, they do not identify all injuries. In contrast, CT has higher sensitivity but has greater radiation, and its use is more appropriate in children over 8 years of age. Conclusion: With knowledge of cervical spine anatomy and the characteristic injuries seen at different stages of development, emergency physicians can make informed decisions about the appropriate modalities for diagnosis of pediatric cervical spine injuries.